How to manage anterior epistaxis secondary to hypertension?

Management of Anterior Epistaxis Secondary to Hypertension

For anterior epistaxis in hypertensive patients, prioritize immediate local control with nasal compression and topical vasoconstrictors while avoiding aggressive acute blood pressure reduction, which can cause end-organ ischemia. 1

Immediate Local Control Measures

First-Line Intervention: Nasal Compression

• Position the patient sitting upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach 1, 2
• Apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 1, 2
• The patient should breathe through their mouth and spit out blood rather than swallowing it 1, 2
• Compression alone resolves the vast majority of anterior epistaxis cases 2

Common Pitfall: Insufficient compression time is a frequent error—the full 10-15 minutes must be maintained without interruption 1

Second-Line: Topical Vasoconstrictors

• If compression alone fails, clear clots from the nose, then apply topical vasoconstrictor (oxymetazoline or phenylephrine spray) and continue compression for 5 additional minutes 1, 2
• This approach resolves 65-75% of epistaxis cases that don't respond to compression alone 1, 2
• Be aware that vasoconstrictors may carry increased risk of cardiac or systemic complications in susceptible patients 2

Third-Line: Nasal Packing

• If bleeding continues despite compression and vasoconstrictors, proceed to nasal packing 3, 2
• Use resorbable packing materials for hypertensive patients, especially those on anticoagulation or antiplatelet medications 3, 1, 2
• Resorbable packing reduces likelihood of additional bleeding during removal, improves patient comfort, and protects the airway 3

Blood Pressure Management: A Critical Distinction

Avoid aggressive acute lowering of blood pressure during active epistaxis—this is a crucial pitfall that can cause or worsen renal, cerebral, or coronary ischemia 1

Key Principles:

• Monitor blood pressure but base control decisions on bleeding severity, inability to control bleeding with local measures, individual comorbidities, and risks of BP reduction 1
• The relationship between epistaxis and hypertension remains controversial, with causality unproven despite hypertension prevalence of 17-67% in epistaxis patients 1
• Focus on local hemostatic measures first rather than systemic BP manipulation 1

This represents a paradigm shift from older approaches that emphasized immediate BP reduction

Anticoagulation Considerations

• Check anticoagulant/antiplatelet status (warfarin, aspirin, clopidogrel) 1, 2
• Do not discontinue anticoagulation or antiplatelet agents unless bleeding cannot be controlled with local measures 3, 1
• Consider reversal agents only for severe refractory bleeding, not as first-line management 3, 1
• For patients on these medications, resorbable packing is strongly preferred over nonresorbable materials 3, 2

Advanced Interventions When Initial Measures Fail

Visualization and Cautery

• Perform anterior rhinoscopy to identify the bleeding source after removing any blood clot 3
• When cautery is chosen, anesthetize the bleeding site and restrict application only to the active or suspected site(s) of bleeding 3
• Silver nitrate cauterization has the highest success rate at 80% and offers the benefit of no follow-up requirement 4

Nasal Endoscopy

• Perform or refer for nasal endoscopy if bleeding precludes identification of a bleeding site despite nasal compression 3
• Endoscopy can localize the bleeding site in 87-93% of cases and is particularly useful for recurrent epistaxis despite prior treatment 3, 2

Surgical Options for Persistent Bleeding

• For bleeding uncontrolled by packing, consider arterial ligation or embolization 3, 2
• Endoscopic ligation of sphenopalatine artery (ELSA) demonstrates superior outcomes with immediate success, shorter hospital stay, lower recurrence rates, and higher patient satisfaction compared to other surgical options 5

Prevention of Recurrence

Once bleeding is controlled:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 1, 2
• Recommend saline nasal sprays to keep mucosa moist 1, 2
• Advise humidifier use in dry environments 1, 2
• Instruct patients to avoid nose picking, vigorous nose blowing, and nasal manipulation for at least 7-10 days 2, 6

Indications for Hospitalization

Hospitalize if:

• Bleeding not controlled after 15 minutes of continuous pressure 1, 2
• Hemodynamic instability (tachycardia, hypotension) 1, 2
• Severe bleeding (duration >30 minutes over 24 hours) 1, 2
• Posterior bleeding source, which is more common in older hypertensive patients 1

Documentation and Follow-Up

• Document the outcome of intervention within 30 days or document transition of care for patients treated with nonresorbable packing, surgery, or arterial ligation/embolization 3
• Routine follow-up is recommended for patients who have undergone invasive treatments to assess for complications and recurrent bleeding 2